Statewide Senior Action Conference. Mark Kissinger. Division of Long Term Care Office of Health Insurance Programs.

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1 Statewide Senior Action Conference Mark Kissinger Division of Long Term Care Office of Health Insurance Programs October 10, 2012

2 Plan released on the MRT website Care Management for All is a key element of the future 2

3 To give one entity responsibility for assessing and arranging services and care management toward: Improving outcomes for enrollees Prevent or delay decline due to chronic conditions Reduce the need for acute care services Improving satisfaction with life status for enrollees and caregivers Producing savings for payers 3

4 An entity designated under Public Health Law (PHL) 4403-f Has a certificate of authority (COA) under Article 44 to: Meet member needs for health and long term care services Receive capitated payment(s) for benefit package services (per member/month) 4

5 Adults (Age 18 and older) Able to live safely in the community upon enrollment In need of the long term care services of the plan for at least 120 days (nursing, therapy or aide services in the home; or adult day health care; or social day care if used as a substitute for personal care services) 5

6 Cannot be concurrently enrolled in a HCBS waiver program (LTHHCP, NHTD, TBI); OMRDD day treatment; or hospice at time of MLTC enrollment Can be enrolled in Medicare Advantage Plan concurrently but not Medicaid Managed Care 6

7 Three MLTC models 1. Partially Capitated Managed LTC 2. Program of All-Inclusive Care for the Elderly (PACE) 3. Medicaid Advantage Plus (MAP) 7

8 Capitated for some Medicaid services only Benefit package is long term care and ancillary services including home care, unlimited nursing home care Primary and acute care covered by FFS Medicare or Medicaid 16 plans offer this product September 2012, enrollment = 53,873 increasing every day Census ranges from 125 to 12,704 DOH had a moratorium on the development or expansion of new partially capitated plans between

9 Medically necessary services including: Care management Home care Nursing home care (unlimited) PERS OT, PT, Speech therapies (inhome and outpatient) Medical and social day care Dental Optometry Podiatry Audiology Transportation DME Social and environmental supports Plan pays for Medicare cost sharing on nursing home, DME, outpatient therapies 9

10 Federal program type for Medicare and Medicaid at State option Capitated for all Medicare and Medicaid services Most integrated of the MLTC models Day center / clinic based Provider network usually small Benefit package includes all medically necessary services primary, acute and long term care 8 plans now offer this product April 2012 enrollment = 4,314 Range = 81 3,074 1New PACE program is under development 10

11 All medically necessary services including: Inpatient hospital Nursing home (unlimited) PT, OT, Speech Prescription drugs Physician (primary care and specialist) Home care Transportation Laboratory and X-ray Emergency transportation Medical supplies and equipment Dental care Vision care Podiatry Social day care Mental health Social and environmental supports 11

12 o o o o o Capitated for Medicare and Medicaid under two separate contracts (Federal and State) All plans must cover the Combined Medicare and Medicaid Benefit Package as defined by DOH Plans must meet both Medicare and Medicaid requirements Challenge is to have this appear seamless to the member 8 plans now offer this product o April 2012 census = 1,875 o Range =

13 All Medicare services All Medicaid services with the exception of some specialized mental health services 13

14 2011 Budget legislation requires: All dual eligibles who are - Age 21 and older and - In need of community-based long term care services for more than 120 days.. Must enroll in a MLTCP or other Care Coordination Model Duals between 18 and 21 remain voluntary 14

15 1115 Waiver approval was secured from CMS 8/31/12 Eliminates the need to score as Nursing Home eligible upon enrollment Definition of community-based long term care services includes: Personal care services Home health services Adult day health care Private duty nursing 15

16 Working with HRA to determine most effective, efficient way to transition people Will not take place all at once By program By borough Consumer Choice preferred but Auto Assignment for those who do not Must ensure continuity of care plan and service provider Significant educational component for people new to system and transitioning Enrollment of those receiving Consumer Directed Personal Assistance services will not begin until September,

17 Several groups are not eligible to enroll in MLTC or care coordination models until program features and reimbursement rates are developed These include people in: Traumatic Brain Injury (TBI) Waiver Nursing Home Transition and Diversion (NHTD) Waiver Assisted Living Program (ALP) Office of People with Developmental Disabilities (OPWDD) Wavier 17

18 There must be a choice of plans in urban areas, at least one in rural counties Upstate expansion will be county by county, as sufficient MLTC plan and CCM model capacity is developed 18

19 New law eliminates previous requirement for designation by Senate, Assembly or Commissioner or Health before applying Applications for new entities or new lines of business and expansions have been posted on DOH website: Requires: Adequate legal structure Identification of service area and target population (including any special populations) Character and competence review Contracted network review Description of care management model, grievance system Demonstration of financial capability and capitalization 19

20 Statute allows up to 75 MLTC Certificates of Authority 42 COAs for new MLTCs can be approved Applicants approved for a COA enter into a contract with DOH A readiness review is conducted before operations begin 20

21 Mandatory Population: Dual eligible, aged 21 and over, receiving community based long term care services for over 120 days, excluding the following for now: Nursing Home Transition and Diversion waiver participants; Traumatic Brain Injury waiver participants; Nursing home residents; Assisted Living Program participants; Dual eligible that do not require community based long term care services. 21

22 In addition to those who must enroll in a Managed Long Term Care Plan or Care Coordination Model, the following people may voluntarily enroll: Dual eligible, 18-21, in need of community based long term care services for over 120 days. Dual eligible age and non-dual eligible age 18 and older assessed as nursing home eligible. 22

23 People New to Service Beginning July 1, Any dual eligible case new to service, fitting the mandatory definition in any New York City county will be identified for enrollment and referred to the Enrollment Broker for action. Enrollment Broker will provide with educational material, list of plans/ccms, answer questions and provide assistance contacting a plan if requested. Plan/CCM will conduct assessment to determine if eligible for community based long term care. Plan/CCM transmits enrollment to Enrollment Broker 23

24 Enrollment will be phased-in by service type by borough by zip code in batches. People will be given 60 days to choose a plan according to the following schedule: July 1, 2012: Begin personal care* cases in New York County. August 1, 2012: Continue personal care cases in New York County. September, 2012: Continue personal care cases in New York County and begin personal care in Bronx County; and begin consumer directed personal assistance program cases in New York and Bronx counties. October, 2012: Continue personal care and consumer directed personal assistance program cases in New York and Bronx counties and begin Kings County. 24

25 November 2012: Continue personal care and consumer directed personal assistance program cases in New York, Bronx and Kings counties December 2012: Continue personal care and consumer directed personal assistance program cases in New York, Bronx and Kings Counties and begin Queens and Richmond counties January 2013: Initiate enrollments citywide of long term home health care program, home health over 120 days, adult day health care program and private duty nursing cases not enrolled under personal care case activity. 25

26 February 2013 and until all people in service are enrolled: Personal care, consumer directed personal assistance program, long term home health care program, home health over 120 days, adult day health care program and private duty nursing cases in New York, Bronx, Kings, Queens and Richmond Counties 26

27 As plan capacity is established, dually eligible community based long term care service recipients will be enrolled as follows: Phase II: Nassau, Suffolk and Westchester Counties Anticipated January Phase III: Rockland and Orange Counties Anticipated June Phase IV: Albany, Erie, Onondaga and Monroe Counties Anticipated December Phase V: Other counties with capacity Anticipated June

28 Phase VI: Previously excluded dual eligible groups contingent upon development of appropriate programs: Nursing Home Transition and Diversion waiver participants; Traumatic Brain Injury waiver participants; Nursing home residents; Assisted Living Program participants; Dual eligibles that do not require community based long term care services. 28

29 Aging network are viable subcontractors to MLTC plans Services must be appropriately valued both by the plan and the provider 29

30 If you have any specific questions about MLTC, please send an to Additional information on MLTC is available on the Department s website at: esign/supplemental_info_mrt_proposals.htm 30

31 Send to me 5 regulatory or policy changes to make implementation of all of these reforms easier. Stay engaged and active. Work with your Association to provide quality feedback. 31

32 Mark Kissinger s contact information: mlk15@health.state.ny.us Stay informed and empowered